Diabetes
Diabetes is a metabolic disorder characterized by hyperglycemia due to ineffective insulin secretion and/or insulin utilization. Definitions * Diabetes: see diagnosis section. A fasting plasma glucose level of 7.0 mmol/L, a 2-hour plasma glucose value in a 75 g oral glucose tolerance test of 11.1 mmol/L or a glycated hemoglobin (A1C) value of 6.5% * Pre-diabetes: impaired fasting glucose, impaired glucose tolerance, or an HbA1c between 6.0-6.4%. These people are at increased risk of developing diabetes and its macrovascular complications * Metabolic syndrome: Elevated waist circumference, triglycerides, reduced HDL-C, elevated Blood Pressure, elevated fasting plasma glucose Symptoms *Hyperglycemia: polydipsia, polyuria, unexplained weight loss, polyphagia, blurred vision, fatigue, dry mouth, dry skin, arrhythmia, decrease LOC *Hypoglycemia: sweating, palpitations, sweating, clammy, blurred vision, dilated pupils, nausea, vomiting, confusion, seizures, decrease LOC Complications Microvascular * Retinopathy * Neuropathy * Nephropathy Macrovascular * Cardiovascular disease * Cerebrovascular disease * Peripheral Vascular disease Screening * No screening for T1DM * T2DM ** Every 3 years >/= 40 years old or high risk with fasting plasma glucose and/or HbA1C. ** Screen earlier +/- more frequently pending risk factors ** Risk factors: first degree relative, member of high risk population (South Asian, Hispanic, Aboriginal, Asian, African), history of pre-diabetes, history of gestational DM, history of macrosomic infant, presence of end organ damage associated with DM, vascular risk factors (HDL<1.0, TG >1.7, HTN, overweight, abdominal obesity), associated diseases (PCOS, acanthosis nigricans, OSA, bipolar, schizophrenia, depression, HIV), drug use (steroids, antipsychotics, HIV treatment), endocrine disorders * Risk calculators: ** CANRISK (ages 40-74) - low/moderate/high groups *** age, sex, BMI, waist circumference, ethnicity, physical activity, diet, HTN, history of dysglycemia, family history, education level *** CANRISK TOOL ** FINDRISC - low/moderate/high groups *** FINDRISC TOOL Diagnosis *If asymptomatic a r'epeat' confirmatory laboratory test on another day is indicated to confirm diagnosis *If symptomatic a diagnosis made. No confirmatory test required. *HbA1c is better predictor of macrovascular complications. HbA1c cannot 'be used in patients with hemoglobinopathies, iron deficiency, hemolytic anemias, severe hepatic/renal dsease *HbA1c not recommended in children, teens, pregnant woman or suspected type 1 diabetes *If FPG 5.6-6.0 or A1c 5.5-5.9 + >1 risk factors consider 75 gram OGTT Prevention *No prevention strategies for T1DM *Lifestyle changes: diet, exercise (moderate to high levels), and weight loss **150minutes/week moderate to vigorous aerobic activity **Resistance training 2x/week *Medications: In individuals with impaired glucose tolerance metformin or acarbose can be used to reduce risk of T2DM Management General Principles *Chronic care model - important to advocate at the community and health system level *Support self management, regular follow-up, provide patient centered education *Use interdiscipinary team approach with shared care model *Consider specialist involvement for children with DM, T1DM, women with diabetes in pregnancy, complex T2DM Targets *'HbA1c < 7% '''general population *Can consider target '''HbA1C <6.5% to lower risk of nephropathy and retinopathy if young and healthy *'HbA1C 7.1-8.5%' in patients with one of the following: multiple severe hypoglycemic episodes, unaware of hypoglycemia, multiple co-morbidities, fragility, limited life expectancy, high level of functional dependency, extensive coronary artery disease at high risk of ischemic events, longstanding diabetes for whom it is difficult to achieve an A1C <7.0% despite effective treatment *Elevated fasting and post-prandial glucose confer risk of cardiovascular disease **Fasting glood gluocse 4.0-7.0 **Post-prandial 5.0-10.0 Non-pharmacologic Strategies Diet: can lower HbA1c 1-2% *Consider referral to dietician *Recommend foods with low glycemic index (lower ability to raise blood glucose) *Dietary fiber (soluble) decreases post-prandial glucose by slowing gastric emptying and delaying absorption *Recommend saturated fats <7% *Canada's Food Guide *Diabetic Food Handout - CV toolbox *Diets that have been shown to help glycemic control: Mediterranean, vegan/vegetarian, DASH diet *Patients with Type 1 insulin should be taught to match insulin to carbohydrate quantity and quality * Insulin users with ETOH at risk of delayed hypoglycemia. Should reduce insulin, increase BG monitoring or increase carbohydrate intake Exercise * 150 minutes moderate to vigouros exercise (aerobic) * Resistance exercise 2-3x per week * People with diabetes that want to start exercising at risk of CVD à baseline ECG +/-stress test, fundoscopic exam, neuropathy screen * Can use exercise prescription Pharmacotherapy *If HbA1c <8.5 - start lifestyle changes and consider metformin *If HbA1c > 8.5% - start metformin immediately. Consider combination therapy. *After diagnosis and starting therapy it should take 3-6 months to reach target HbA1c *Insulin has the largest effect on lowering HbA1c Examples: *Biguanide **Metformin: weight neutral, no hypoglycemia ***S/E: N/V/D. Contraindication: CrCl<30ml/min **Glumetza *DPP4- inhibitor **Increase amount of circulating insulin. Less risk of hypoglycemia, risk pancreatitis **e.g. Siitagliptin (januvia), Linagliptin (Trajenta) *Sulfonylurea **Risk of hypoglycemia **e.g. Glyburide, Gliclazide (Diamicron) * Insulin *INSULIN PRESCRIPTION *When starting insulin consider stopping insulin secreatogoues due to risk of hypoglycemia. Monitoring Type 1 diabetics: * should check finger prick glucose >3x/day and HbA1C q3 months * Real time continuous glucose monitoring may be used to improve glycemic control and reduce hypoglycemia * During periods of acute illness and elevated blood glucose/or symptoms of DKA patients should be instructed to test for blood ketones or urine ketones * Individuals with type 1 diabetes should be instructed to perform ketone Type 2 diabetics: * HbA1c q3months when glycemic targets not being met or when therapy is being changed * On insulin once/day: self monitored glucose once/day at variable times * On insulin >1/time: check glucose at least 3x/day with both pre/post-prandial values * In T2DM not on insulin consider self monitoring glucose (individualized). Consider risk of hypoglycemia with oral antiglycemics, not acheiveing control to assist with compliance, Calibrate blood glucose monitors once/year Diabetic Ketoacidosis (DKA) Hyperosmolar Hyperglycemia Syndrome Hypoglycemia *Definition: blood sugar <4 + autonomic symptoms + response to carbohydrate load *Symptoms: trembling, palpitations, sweating, anxiety, hunger, nausea, confusion, weakness, trouble concentrating, decrease LOC *Treatment of mild-moderate hypoglycemia- 15 grams carbohydrate load (dextrose tablets, lifesavers x 6, 3/4 cup orange juice, 1 tablespoon of honey), retest in 15 minutes Vascular Protection *Statin therapy **Age > 40 (regardless of LDL-C) **Earlier if have macro/microvascular complications **DM > 15 years duration and age >30 *ACEI/ARB **Age >55 **Earlier if have macro/microvascular complications **Perindopril 8 mg PO daily or Ramipril 10mg Po daily or Telmisartan 80mg PO daily (full dose) - titrate up *ASA **All patients with diabetes who have had a vascular event *A1c < 7%, BP < 130/80, Cholesterol LDL<2.0, Drugs to protect heart (ACEI, statin, ASA), Smoking cessation, exercise, healthy eating Other considerations *pneumococcal vaccination: over the age of 18 x 1 (at diagnosis) then one time revaccination if >65 (ensure >5 years between vaccinations) *Annual influenza vaccine Patient Care Flow Sheet Patient Care Flow Sheet *A1C q 3 months *ACr - yearly (target <2.0) *Retinopathy check - yearly *BP check (every visit) *Neuopathy check - monofilament - yearly *LDL-C yearly (new guidelines changing**) References Canadian Diabetes Guidelines